Provider Demographics
NPI:1003246257
Name:WALLACE, JOYCE (CRNA, ARNP)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CRNA, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 ALAMEDA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-6903
Mailing Address - Country:US
Mailing Address - Phone:419-512-3374
Mailing Address - Fax:
Practice Address - Street 1:2165 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3819
Practice Address - Country:US
Practice Address - Phone:904-387-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-24
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9309567163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse